Tuesday, June 30, 2009

Psychiatry’s DSM-V Process: Now A Bar Room Brawl

Psychiatry’s diagnostic manual is due for a revision. But what began as a group of top scientists reviewing the research literature has degenerated into a dispute that puts the Hatfield-McCoy feud to shame.

The latest installment in this remarkable episode of American psychiatry involves an editorial by Dr. Allen Frances, the chairman of the committee that created the current version of the the DSM, the DSM-IV. The editorial has not even been officially published (it is in press at Psychiatric Times) but already it has made the rounds of the blogs and is being read and debated widely. Now, the APA has just released this rather stunning response.

Those who are not in psychiatric circles might find their eyes glazing over a bit as they read these articles. But we are witnessing here something dramatic and important. Psychiatry is wrestling with its identity, and in the process is creating the next set of ideas that will guide how real people are diagnosed and treated for years to come. The stakes for everybody are high.

In his editorial, Dr. Frances criticizes the evolving DSM-V on multiple levels, and makes the following claims:

--The process of writing the manual is less transparent and less inclusive than the process he oversaw when he chaired the DSM-IV committee.

--The underlying science of psychiatry has not advanced enough to merit the kind of extreme makeover proposed by the DSM-V chairpeople:

"The simple truth is that descriptive psychiatric diagnosis does not need and cannot support a paradigm shift. There can be no dramatic improvements in psychiatric diagnosis until we make a fundamental leap in our understanding of what causes mental disorders. The incredible recent advances in neuroscience, molecular biology, and brain imaging that have taught us so much about normal brain functioning are still not relevant to the clinical practicalities of everyday psychiatric diagnosis. The clearest evidence supporting this disappointing fact is that not even one biological test is ready for inclusion in the criteria sets for DSM-5."

--The main change being proposed—the official inclusion of a series of rating scales into the diagnostic criteria—is poorly conceived because busy clinicians will reject this extra paper-work.

--Other proposed changes in DSM-V will make it too easy to over-diagnose a range of conditions:“The result would be a wholesale imperial medicalization of normality that will trivialize mental disorder and lead to a deluge of unneeded medication treatment--a bonanza for the pharmaceutical industry but at a huge cost to the new false positive "patients" caught in the excessively wide DSM-V net. They will pay a high price in side effects, dollars, and stigma, not to mentions the unpredictable impact on insurability, disability, and forensics.”

Frances’ article is compelling, not only because of the substance of his arguments but because of his clear and forceful writing style. With each sentence, you get a sense that this man has carefully thought through all of these issues and is passionately concerned about the future of his field.

The APA’s response, on the other hand, is a weird mixture of bureaucratese and mean-spiritedness. The bureaucratese I can understand—after all, this is a letter crafted by committee. But the nasty tone of the response is astonishing and undignified.

The APA gets off to cringing start by calling Frances and his colleagues liars:

“The commentary “A Warning Sign on the Road to DSM-5: Beware of its Unintended Consequences” by Allen Frances, M.D., submitted to Psychiatric Times contains factual errors and assumptions about the development of DSM-V that cannot go unchallenged. Frances now joins a group of individuals, many involved in development of previous editions of DSM, who repeat the same accusations about DSM-V with disregard for the facts.”

Wow. Can’t grown men have disagreements with one another without resorting to this kind of language? I might have started with something more like, “The commentary “A Warning Sign on the Road to DSM-5: Beware of its Unintended Consequences” by Allen Frances, M.D., is a thought-provoking critique of the DSM-5 process. While we respect and appreciate Dr. Frances’ leadership in American psychiatry over the years, we disagree with several of his points.” (Note to APA--send me all future "defense letters" for editing, at no charge).

After this, there are six paragraphs addressing some of Frances’ specific points. We hear that the DSM-V process has actually been “the most open and inclusive ever” and that the much villified “confidentiality agreement” was created to protect intellectual property rather than to keep proceedings secret. There is a defense of the usefulness of symptom rating scales: “Recent studies underscore the readiness of clinicians in both primary care and specialty mental health settings to adopt dimensional instruments on a routine basis.”

And there is a reasonable reminder of why some changes in the criteria are needed: “Clinicians complain that the current DSM-IV system poorly reflects the clinical realities of their patients. Researchers are skeptical that the existing DSM categories represent a valid basis for scientific investigations, and accumulating evidence supports this skepticism.”

But after a brief, not terribly convincing rebuttal of the merits of Frances' argument, the writers decide to conclude by getting mean and personal again. This time, they accuse Dr. Frances of being deceptive in not disclosing his financial interests in DSM-IV (he is co-author of one book that teaches doctors how to use the manual). Then, they opine that Frances’ real motive in criticizing DSM-V is not a desire to improve diagnosis, but simply greed.

“Both Dr. Frances and Dr. Spitzer have more than a personal “pride of authorship” interest in preserving the DSM-IV and its related case book and study products. Both continue to receive royalties on DSM-IV associated products. The fact that Dr. Frances was informed at the APA Annual Meeting last month that subsequent editions of his DSM-IV associated products would cease when the new edition is finalized, should be considered when evaluating his critique and its timing.”

In other words, Dr. Frances wrote his editorial because he was just informed that once DSM-V is published, the APA will no longer publish new editions of books introducing psychiatrists to the outdated DSM-IV. Somehow, I doubt that this was exactly a news flash to Dr. Frances.

It is disturbing that the APA and DSM leadership would accuse Dr. Frances and his colleagues of being greedy, deceptive, and dumb. Who do they think they are--bloggers?

19 comments:

Dark Jay
said...

I saw Dr. Frances' letter yesterday at Mindhacks and burst into applause. I fully agree with his demand for greater transparency and his concerns about unintended consequences. The APA's response is unfortunate, to say the least. I am a big stickler for diagnostic accuracy and fully believe that the DSM needs revision. But the myriad "influences" being exerted on the process must be illuminated. Otherwise, it's just a matter of time before we encounter Prenatal Bipolar Disorder. Aieeeeeee!

What a sad state of affairs. And I bet the APA members accusing Frances of COI are stuffing their pockets with Pharma money while pointing their collective finger at Frances. Sorry -- the APA should be renamed the American Proctological Association... for obvious reasons.

As I read the APA response it was clear they are really getting down and dirty. Then I saw that Alan Schatzberg authored the response, and I understood. This kind of smearing, ad hominem, mean spirited innuendo is his trademark. He tried to pull a stunt like that on me not long ago and I handed him his head.

I find this issue regarding DSM V very personal, because the usual suspects in our field are the proverbial captains of the Titanic and are steering the ship of psychiatry right into the iceberg of reality and will sink it, killing all who were foolishly on board thinking it unsinkable.

But, I have to say the end of your post equally compelled me to comment. Sarcastic or not, your end sentence about Dr Frances was just wrong to make. The APA is just projecting, Dr Carlat, so don't worry about being politically correct and call it for what it is, a bunch of greedy, insensitive egomaniacs who will stop at nothing to ram their agenda down the throats, both figuratively and literally, of well intended physicians and innocent patients.

DSM V gets published as is, I will seriously have to reconsider my professional career. Not a flippant comment, but a serious intention.

Lol. Well I guess you have a job (editing) after they kick you out of the APA for (gasp) being honest. In think their journal is also going south having rejected an editorial by Robert Spitzer (who started the DSM) critical of the process and publishing pharma friendly fluff pieces on the DSM-5 process.

It will be interesting to see if this (DSM-5) actually gets published and if real clinicians actually care. How funny in a completely pathetic way. What valid scientific endeavor takes place by cloistering a bunch of academics in work groups to re-write the way we look at reified constructs? (ideas that have no reality other than what we chose to give them) Psychiatry just keeps opening up more of its own veins in a crude attempt to bleed out a cure and completely misses what is wrong with it. I give this guy credit for admitting that all the advances in neuroscience have made not one bit of difference to the practical world of psychiatry. Get ready to dx everything. I am so disordered. I have that adult reactive attatchment disorder as I hate almost everyone and the bitterness disorder too. Who will fill out my disability forms?

"The main change being proposed—the official inclusion of a series of rating scales into the diagnostic criteria—is poorly conceived because busy clinicians will reject this extra paper-work."

And double ACK to this (we cannot refine physiologically influenced disorders until we can develop a biological test for them? That's just...crazy):

"The incredible recent advances in neuroscience, molecular biology, and brain imaging that have taught us so much about normal brain functioning are still not relevant to the clinical practicalities of everyday psychiatric diagnosis. The clearest evidence supporting this disappointing fact is that not even one biological test is ready for inclusion in the criteria sets for DSM-5."

If you missed the New Yorker's interesting article, years ago, on the DSM, here's the link:http://tinyurl.com/ly95es

Excerpt:“When Bob was appointed to the DSM-III, the job was of no consequence. In fact, one of the reasons Bob got the job was that it wasn’t considered that important. The vast majority of psychiatrists, or for that matter the A.P.A., didn’t expect anything to come from it.” This attitude was particularly prevalent among Freudian psychoanalysts, who were the voice of the mental-health profession for much of the twentieth century. They saw descriptive psychiatry as narrow, bloodless, and without real significance. “Psychoanalysts dismiss symptoms as being unimportant, and they say that the real thing is the internal conflicts,” Klein says. “So to be interested in descriptive diagnosis was to be superficial and a little bit stupid.”

" There can be no dramatic improvements in psychiatric diagnosis until we make a fundamental leap in our understanding of what causes mental disorders. The incredible recent advances in neuroscience, molecular biology, and brain imaging that have taught us so much about normal brain functioning are still not relevant to the clinical practicalities of everyday psychiatric diagnosis."

Maybe the source of mental disorders are in the *mind*, not just the brain. The *cause* is not in the body, just the indicators.

There is far more to psychiatry than behaviorism and chemistry. I think its obvious that psychiatric disorders lie predominantly within the *psyche*, and we have over a centuries worth of reproducible methods, models, and research that sheds light on many of these problems.

While the spectacular advances in neuroscience, molecular biology, and brain imaging also shed some critical light on the multifaceted nature psychiatric disorders, looking at things from a strictly biological angle seriously cripples our effectiveness, and is one of the major reasons why therapy is often so ineffective.

I just discovered this blog and I like it. I run http://www.schizoaffective.org , it is a support group and members of the group are confused about the proposal to eliminate schizoaffective as a diagnosis. These are fragile people and having their dx changed to schizophrenia, as is currently being discussed, will confuse and upset them. But maybe it will also cause people who have been labeled with schizoaffective to see psychiatric labels for what they really are, unscientific and not based on medical facts. I'm sure the following quote by Dr. Mosher can also be applied to the upcoming DSM V.

DSM IV is the fabrication upon which psychiatry seeks acceptance by medicine in general. Insiders know it is more a political than scientific document. To its credit it says so

Dr Frances wrote:"...The incredible recent advances in neuroscience, molecular biology, and brain imaging that have taught us so much about normal brain functioning..."

Now, this is what I find really odd: if one knows how a "normal" brain functions, then one has a comparator, a benchmark, against which to work. One may then compare other brains to this ideal model and, provided that one had the requisite skill, modify those that do not meet the criteria for normality that one has previously identified. Hmmm. Sounds a bit fucking Mengler-esque, to me!

I still want to know who it is who decides what "normal" amounts to. The only people who look abnormal, to me, are those who seem to think that they have a right to tell others how they should conduct themselves - and I find that disturbing for any number of reasons (first and foremost because, taken to its logical extreme, the whole world will end up looking like the person(s) in charge).

So, can we find the personification of the "normally-functioning brain," and then we can all emulate this person and save psychiatry from a lot of in-fighting!

Julian wrote:"While the spectacular advances in neuroscience, molecular biology, and brain imaging also shed some critical light on the multifaceted nature psychiatric disorders, looking at things from a strictly biological angle seriously cripples our effectiveness, and is one of the major reasons why therapy is often so ineffective."

----That's why the best clinicians don't look strictly from a biological angle. Neither do they ignore or diminish it.

I think its obvious that psychiatric disorders lie predominantly within the *psyche*, and we have over a centuries worth of reproducible methods, models, and research that sheds light on many of these problems.

Hard to disagree more with you on that one. And that is a debate far too long and complicated for now.

looking at things from a strictly biological angle seriously cripples our effectiveness, and is one of the major reasons why therapy is often so ineffective.

The psycho-social based therapies (additional to generic social support) are not that effective in the real world either.

I also do not see that psych has been entirely hijacked by biological based views. If anything in my area it is the opposite, the psycho-social view holds dominant, (incorrectly, IMHO).

Dark Jay -- You imply that you are a physician, being a "big stickler for diagnostic accuracy." Yet, you say "Aieeeeeeee!" to the thought of prenatal bipolar disorder. Perhaps you do not keep up with the science?http://tinyurl.com/mafofo

Those psychiatrists who fail to follow the science and allow it to inform their work risk becoming quaint (if dangerous) anachronisms. And, fortunately, no amount of pharma bashing or teeth gnashing will save them.

Matt - the ones who get to decide what qualifies as "normal" are a group of aging white guys who probably are all a little off themselves.

Even my doctor, who is wedded to the biomedical model and eschews the biopsychosocial model, thinks of the DSM as a giant doorstop. He thinks it, and the process involved in creating it, are a joke.

In fact, it seems based on what I'm reading on twitter, in the news, and on blogs, that many, many clinicians think very little of the DSM. I'm beginning to think the only ones who see the DSM as being anything but a joke are those who work for pharma, and those who take money from pharma.

I noticed most members of the DSM-V task force are MDs, PhDs, and/or professors connected with clinical practice or research.

Why are many critical stakeholders missing from the task force/committees? Mental health advocacy groups, healthcare managers, patients, and policymakers should be part of this process. So many lives are affected by this mental health bible, and I am shocked at the lack of representation and diversity of the task force.

Another concern is that Western Psychiatric hospital associated with the leader of this project–Dr. David Kupfer. While Western Psych and its affiliated medical school, the University of Pittsburgh, both have a good reputation for academics, Western Psychiatric hospital has a terrible reputation for patient care. Clinicians and other health care workers have noted this.